TiLite Seating System Order Form
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- Ira Ward
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1 Effective October 15th, 2018 (New Items in Red) Page 1 of 5 DEALER INFORMATION RTS INFORMATION Dealer: Account #: RTS: Phone: PO: Ordered By: SHIP TO INFORMATION Mark For: Name: Ship Via: TiLite Sales Rep: Address: TiLite Information: Promo Code: City: State: Zip: Ship Date: Order #: Phone: Fax: Please or Fax to the Permobil Manual Customer Service Team at US_Box_TiLite_Orders@permobil.com or / INSTRUCTIONS ROHO Seating available with new TiLite chair orders only. SHIPPING SSH3 Install ROHO AGILITY back (Must select seat back height range and set at measurement or Fixed Height when selected.) BACK SUPPORTS ROHO AGILITY Shell Height (Not available with AGILITY Carbon) 20 (Not available with AGILITY Carbon STD ROHO AGILITY MINIMUM CONTOUR (Not available with 20" Shell Height, Non-Folding Fixed Height Backs or Custom Height Rigidizer Bar.) BRS5 Foam $510 E2611 BRS6 Foam + Lumbar $615 E2613 BRS7 Foam w/ Air Insert $720 E2620 ACB1 AGILITY Carbon Upgrade (Not available with TWIST, X Series or Bolt-on Push Handles) $370 BRS8 Foam w/ Air Insert + Lumbar $720 E2615 Quick Release (Not available with AGILITY Carbon Upgrade) OR Fixed (Not available with 18 or 20 Shell Height or Folding Chairs.) ROHO AGILITY MID CONTOUR (Not available with Non-Folding Fixed Height Backs or Custom Height Rigidizer Bar.) BRS9 Foam w/ Air Insert $730 E2620 ACB2 AGILITY Carbon Upgrade (Not available with TWIST, X Series or Bolt-on Push Handles) $370 BRS10 Foam w/ Air Insert + Lumbar $730 E2615 Quick Release (Not available with AGILITY Carbon Upgrade) OR Fixed (Not available with 18 or 20 Shell Height or Folding Chairs.) ROHO AGILITY MAX CONTOUR (Not available with 10" or 13" Shell Height, Non-Folding Fixed Height Backs or Custom Height Rigidizer Bar.) BRS11 Foam w/ Air Insert $855 E2620 BRS12 Foam w/ Air Insert + Lumbar $855 E2615 Quick Release OR Fixed (16 Shell Height only. Not available with Folding Chairs) COMFORT ACTA RELIEF BRS13 Acta Relief $730 E2615 COMFORT Shell Height STD CPSB1 Comfort Privacy Shield $40 COMFORT Install Do Not Install Install on TiLite Chair SHORT FOLDING SEAT BACK HEIGHT RANGES AND ROHO AGILITY ORIENTATION Shell Height Quick Release Flipped w/ Quick Release Fixed Flipped w/ Fixed Set at: (Use 1/2 increments.) Set at: Set at: Set at: N/A N/A Set at: N/A N/A Set at: MEDIUM FOLDING SEAT BACK HEIGHT RANGES AND ROHO AGILITY ORIENTATION Shell Height Quick Release Flipped w/ Quick Release Fixed Flipped w/ Fixed Set at: (Use 1/2 increments.) Set at: AGILITY Carbon 10 N/A N/A Set at: Set at: AGILITY Carbon 13 N/A N/A Set at: Set at: AGILITY Carbon 16 N/A N/A Set at: N/A N/A Set at: N/A N/A Set at: permobilus.com 2701 West Court Street Pasco, Washington Tel Toll-Free Fax Toll-Free Fax
2 Effective October 15th, 2018 (New Items in Red) Page 2 of 5 BACK SUPPORTS FIXED SEAT BACK HEIGHT AND ROHO AGILITY ORIENTATION (Available only with AGILITY Carbon Upgrade) Fixed Back with Fixed Back with Back Orientation Shell Height Standard Orientation Flipped Orientation Standard OR Flipped Fixed Height BACK SUPPORT SYSTEM ACCESSORIES ULTRASUEDE COLOR INSERTS (Not available with AGILITY Carbon Upgrade.) UPC4 Black Sapphire Red Pepper Burnt Orange Sub-Lime Ultraviolet Espresso $85 PSB1 ROHO Privacy Shield for AGILITY Back $60 ROHO AGILITY LATERALS (Not available with AGILITY Carbon Upgrade. Note: Laterals are sold as each Left and Right.) BRL1 Left Swing-Away with Curved Pad Medium Large X-Large Flush 1/2 Offset 1 Offset 2 Offset BRL2 Right Swing-Away with Curved Pad Medium Large X-Large Flush 1/2 Offset 1 Offset 2 Offset BRL3 Left Fixed with Flat Pad Medium Large X-Large $215 E0956 Flush 1/2 Offset BRL4 Right Fixed with Flat Pad Medium Large X-Large $215 E0956 Flush 1/2 Offset $430 E1028, E0956 $430 E1028, E0956 ROHO ADJUSTABLE SKIN PROTECTION & POSITIONING (Not available with Seat Taper. See page 3 for size chart.) CSH4 QUADTRO SELECT (Fits Seat Widths ) Profile Mid Profile Low Profile $525 E2624 CSH5 QUADTRO SELECT for Seat Widths Profile Mid Profile Low Profile $580 E2625, E2624 CSH8 CONTOUR SELECT (Fits Seat Widths ) $525 E2624 CSH9 CONTOUR SELECT for Seat Widths $580 E2625, E2624 CSH10 ENHANCER (Fits chair widths ) $550 E2624 ROHO ADJUSTABLE SKIN PROTECTION (Not available with Seat Taper. Please see page 4 for size chart.) CSH11 Single Compartment (Fits Seat Widths ) Profile Mid Profile Low Profile $525 E2622 SCD1 Sensor Ready Cushion with Smart Check Device (Not available with Low Profile.) $185 CSH12 Single Compartment for Seat Widths Profile Mid Profile Low Profile $580 E2623,E2622 SCD1 Sensor Ready Cushion with Smart Check Device (Not available with Low Profile.) $185 CSH13 Dual Compartment (Fits Seat Widths ) Profile Low Profile $550 E2624 ROHO AIR / FOAM COMBINATION (Not available with Seat Taper. Please see page 3 for size chart.) CSH14 Hybrid Elite (Fits Seat Widths ) Single Compartment Dual Compartment $540 E2622 SCD1 Smart Check Device (Not available with Dual Compartment) $185 CSH15 Hybrid Elite for Seat Widths (Not available with Single Compartment) $595 E2623, E2622 CSH16 nexus SPIRIT (Fits Seat Widths ) $495 E2622 CSH17 HARMONY (Weight Limit: 275 lbs, Fits chair widths ) $365 E2607 CSH18 AirLITE (Weight Limit: 275 lbs, Fits chair widths ) $230 E2605 COMFORT CSH21 Versa X (Not available with Seat Taper. Please see page 5 for size chart.) $475 E2624 SUPRACOR CSH2 StimuLITE Sport (2 Black 12 x12 to 20 x 20. Please allow an additional 2-3 weeks delivery.). $595 E2603 CSH3 Corbee (2 Black 6 x 6 to 16 x 16. Please allow an additional 2-3 weeks delivery.) $575 E2603 VARILITE CSH6 Evolution (Black only. Please see below for size chart.) $566 E2622 CSH7 Zoid (Black only. See Please see below for size chart.) $566 E2622 Varilite Evolution Varilite Zoid Seat Seat , 12, , 16, 18, , 16, , , , 16, 18, 20, , 18, , 18, , 18, , 18, 20
3 Effective October 15th, 2018 (New Items in Red) Page 3 of 5 QUADTRO SELECT Rear Seat 12 Seat Width 13 Seat 12 N/A N/A N/A N/A N/A N/A N/A 13 N/A N/A N/A N/A 14 N/A Low, Low, Low, N/A 15 N/A Low, Low, Low, Low, N/A 16 N/A N/A Low, Low, Low, Low, Low, 17 N/A N/A Low, Low, Low, Low, Low, 18 N/A N/A Low, Low, Low, Low, Low, 19 N/A N/A Low, Low, Low, Low, Low, 20 N/A N/A N/A N/A Low, CONTOUR SELECT ENHANCER Nexus SPIRIT Seat Seat Seat 14 14, 15, 16, 17, 18, , 15, 16, 17, 18, , 15, 16, 17, 18, 19, 20, , 15, 16, 17, 18, 19, 20, , 17, 18, 19, 20, , 17, 18, 19, 20, , 17, 18, 19, 20, , 15, 16, , 15, 16, , 15, 16, 17, 18, , 15, 16, 17, 18, , 17, 18, 19, 20, , 17, 18, 19, 20, , , , Seat Seat Seat 14 14, 15, , 16, , 16, 17, 18, , 17, , 17, 18, , 18, , , , , , , 18, , 18, , , 18
4 Effective October 15th, 2018 (New Items in Red) Page 4 of 5 Single Compartment Italicized profiles are available without ROHO Smart Check Bolded profiles are available with ROHO Smart Check Rear Seat Width 12 Seat 13 Seat 12 N/A N/A N/A N/A N/A N/A N/A Low, Low, Low, 13 N/A N/A N/A Low, Low, Low, Low, 14 N/A N/A Low, Low, Low, Low, 15 N/A N/A Low, Low, Low, Low, 16 N/A N/A Low, Low, Low, Low, 17 N/A N/A Low, Low, Low, Low, Low, 18 N/A N/A Low, Low, Low, Low, Low, 19 N/A N/A Low, Low, Low, 20 N/A N/A N/A N/A Dual Compartment Rear Seat Width 14 N/A N/A N/A 15 N/A N/A N/A N/A N/A 19 N/A N/A 20 N/A N/A N/A
5 Effective October 15th, 2018 (New Items in Red) Page 5 of 5 Versa X Seat 12 10", 11", 12", 13", 14", 15", 16" 13 10", 11", 12", 13", 14", 15", 16", ", 11", 12", 13", 14", 15", 16", 17, ", 15", 16", 17, 18, 19, ", 15", 16", 17, 18, 19, ", 16", 17, 18, 19, ", 16", 17, 18, 19, ", 17, 18, 19, ", 17, 18, 19, 20 GENERAL Permobil manufactures a wide variety of wheelchairs to meet the varied needs of wheelchair users. The final selection of a particular model, its options and accessories, and its measurements rests solely with the wheelchair user and advising healthcare professional. TiLite wheelchairs must be fitted by a qualified healthcare professional. HCPCS Codes are for reference purposes only. Actual coding and coverage varies by payer. Proper HCPCS coding is not a guarantee of payment. Please verify the appropriate payer s coverage policy. Get the latest order forms at tilite.com. Prices, standard features, options and accessories are subject to change without notice. All rights reserved. Trademarks are identified by symbols and. TiLite, TiFit, the TiLite logo, and The Ultimate Ride are registered trademarks of TiSport, LLC and are licensed to TiLite, LLC. Ride Designs and Corbac are registered trademarks of Aspen Seating, LLC. ROHO, LOW PROFILE and QUADTRO SELECT are registered trademarks of ROHO Inc. Supracor, Stimulite and Corbee are registered trademarks of Supracor, Inc. Varilite is a registered trademark of Cascade Designs, Inc.
Address: STD TWANO5 Sapphire TWANO3 Red Pepper TWANO6 Burnt Orange TWANO7 Sub-Lime TWANO8 Ultraviolet $150
Effective February 1, 2015 (New Items in Red) Page 1 of 7 DEALER INFORMATION RTS INFORMATION Dealer: Account #: RTS: Phone: PO: Ordered By: Email: Email: SHIP TO INFORMATION Mark For: Name: Ship Via: Sales
Address: City: State: Zip: City: State: Zip: TiLite Information. Please Fax to the TiLite Customer Service Team at or
Page 1 of 7 DEALER INFORMATION RTS INFORMATION Dealer: RTS: Phone: Account: PO: Email: Ordered By: SHIP TO INFORMATION Address: Name: Ship Via: City: State: Zip: Address: Phone: Fax: City: State: Zip:
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The average annual per capita paper use in the USA in 2001 was 700 pounds. The average annual per capita paper use in the rest of the world was 110 pounds. This is equal to approximately 28 print outs
ORDER FORM Ver.9.0 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:
C O L O U R S C H U M P - G ORDER FORM Ver.9.0 Rev-072513 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
TiLite. Please Fax to the TiLite Customer Service Team at or
- Print as guide for ordering DEALER INFORMATION ler: Adaptive Specialties RTS INFORMATION RTS: Email: SHIP TO INFORMATION Phone: Page 1 of 9 Email: TiLite Information Name: Ship Via: : Please Fax to the
Order Form SHIP TO INFORMATION. TiLite Information: Promo Code: City: State: Zip: Dealer: Account #: RTS: Phone: PO: Ordered By:
Effective October 15th, 2018 (New Items in Red) DEALER INFORMATION MONO-TUBE RIGID FRAME Order Form RTS INFORMATION Dealer: Account #: RTS: Phone: PO: Ordered By: Email: Email: SHIP TO INFORMATION Mark
M1 - NPO. Dealer Information. Client Information. Client Measurements
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International TiLite Z-Series Order Form
Effective January 2 nd, 2019 (New Items in Red) DEALER INFORMATION International TiLite Z-Series Order Form MONO-TUBE RIGID FRAME RTS INFORMATION Dealer: Account #: RTS: Phone: PO: Ordered By: Email: Email:
FOLDING FRAME. Promo Code: City: State: PC: Ship Date: Order #:
Page 1 of 6 DEALER INFORMATION Client Name: Dealer: Contact No: Address: TiLite Information Promo Code: City: State: PC: Ship Date: Order #: Phone: Fax: Please Email order to orders.au@permobil.com or
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The average annual per capita paper use in the USA in 2001 was 700 pounds. The average annual per capita paper use in the rest of the world was 110 pounds. This is equal to approximately 28 print outs
ORDER FORM Ver.9.0 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:
C O L O U R S S PA Z Z - G ORDER FORM Ver.9.0 Rev-072513 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
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ORDER FORM Ver.9.0 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:
C O L O U R S RAZOR BLADE ORDER FORM Ver.9.0 Rev-072513 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
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C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.072318 Shipping Address * * required F r a
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C O L O U R S ZEPHYR EVERY DAY ORDER FORM Ver.6 Rev-091211 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
Order Form SHIP TO INFORMATION. TiLite Information: Promo Code: City: State: Zip: Dealer: Account #: RTS: Phone: PO: Ordered By:
Effective April 1, 2019 (New Items in Red) DEALER INFORMATION MONO-TUBE RIGID FRAME RTS INFORMATION Dealer: Account #: RTS: Phone: PO: Ordered By: Email: Email: SHIP TO INFORMATION Mark For: Name: Ship
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